Provider Demographics
NPI:1275959769
Name:CULTIVATING CHANGE COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:CULTIVATING CHANGE COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:860-965-2443
Mailing Address - Street 1:4 GLORIA LN
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-2609
Mailing Address - Country:US
Mailing Address - Phone:860-965-2443
Mailing Address - Fax:
Practice Address - Street 1:392 MERROW RD STE B
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3974
Practice Address - Country:US
Practice Address - Phone:860-965-2443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-09
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT000964101YA0400X
CT002338101YP2500X
CT62171041C0700X
CT001475106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty